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Neuromuscular Training & ACL Injury Prevention: A Systematic Review Bialercowski, Christine; Campbell, Sean; Falkner, Sara; Owen, Jessica; Ward, Alex; MacIntyre, Donna; Dumont, Tyler Oct 5, 2006

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Neuromuscular Training & ACL Injury Prevention: A Systematic Review Presented by: Christine Bialkowski, Sean Campbell, Sara Falkner, Jessica Owen & Alexander Ward Supervisors: Donna MacIntyre & Tyler Dumont  Outline z Introduction  to ACL injuries z Purpose of our review z Method z Results z Discussion z Conclusions z Questions  An Introduction to ACL Injuries •  ~70% are non-contact (Arendt et al., 1995)  •  •  Common mechanism = rapid deceleration (I.e. planting/cutting maneuvers or landing from a jump) Females at higher risk than males (4-6x higher in soccer) (Mihata et al., 2006)  Risk Factors zINTRINSIC: – Hormonal – Anatomical – Biomechanical – Neuromuscular  z EXTRINSIC: – Bracing – Physical/visual  perturbations – Shoe-surface interactions (Hewett et al., 2006)  Neuromuscular Mechanisms z Unbalanced medial to lateral quadriceps ratio (Myer et al., 2005, Rozzi et al., 1999)  z Pre-planned vs. unanticipated movements – Increased varus-valgus and internal-external rotation moments (Besier et al., 2001) z Quadriceps-hamstrings antagonist-agonist relationship – Deficits in strength and activation of hamstrings (Solomonow et al., 1987) – Decreased co-activation (F > M) (Petrus C, 2006) (Hewett et al., 2006)  The Need For Prevention z z  ~95,000 new ACL injuries/year If surgery is required – 6 to 24 months of rehab = $17,000/injury (Beynnon et al., 2005, Hewett et al., 1999)  z z  ACL reconstruction does not ensure a return to previous activity levels (Fithian et al., 2002) If left untreated Æ chronic knee instability, secondary joint damage and early OA (Andriacchi et al., 2006)  Purpose of Our Review z Identify  the effectiveness of neuromuscular training programs in the prevention of ACL injury in athletes participating in high risk sports  METHOD  Literature Search • English language • 1996 – August 2006 • MEDLINE, CINAHL, EMBASE, Web  of Science, PubMed, SPORT Discus, CENTRAL and PEDro  Common Search Strategy 1. 2.  Anterior cruciate ligament injur$ or ACL injur$ OR knee injur$ Prevention  3.  1 AND 2  4.  Neuromuscular OR exercise OR training OR balance OR proprioception OR agility OR plyometric$ 3 AND 4  5.  The Search continues… z Grey  literature search (ProQuest Dissertations & Theses database) z Hand search (J. of Orthopedic and Sports Physical Therapy) z Reference list search of included articles z Contacted experts  Study Selection Criteria 1) Subjects were male or female athletes  participating in one or more of the identified high risk sports 2) The intervention was a neuromuscular training program aimed at preventing knee injury 3) An experimental design was used 4) Outcome measure was ACL injury incidence  Exclusion Criteria Rehabilitation intervention post-ACL injury  Search Flow Diagram Web of Science (n=59)  SPORTDiscus (n=208)  EMBASE (n=46)  Cochrane Central Register of Controlled Trials (n=11)  CINAHL (n=96)  PubMed (n=137)  Potentially relevant citations identified through electronic searches (n=736) Citations excluded after title screening (n=582) Abstracts retrieved for review (n=154)  Studies excluded after abstract screening (n=109) Full articles retrieved for detailed review (n=45) Studies excluded after full text review (n=38) Relevant studies included in systematic review (n=7)  PEDro (n=179)  Review Criteria • Sackett’s levels of evidence as updated  by Phillips et al. in the Oxford Centre for Evidence-based Medicine Levels of Evidence (Sackett, 1986, Phillips et al., 2001)  Methodological Quality Criteria • Megens and Harris as modified by Medlicott  and Harris (Megens et al., 1998, Medlicott et al, 2006) • 10 criteria • Strong (8-10); moderate (6 or 7); weak (5 or less)  RESULTS  Levels of Evidence • 5 non-randomized cohort studies • 2 randomized cohort studies • All studies used prospective data  collection methods • All identified as level IIb  Methodological Rigor • Range 3 to 7 (out of 10) • Mean score = 6 • Median score = 7 • 5 studies scored as “moderate” and 2  as “weak”  Methodological Rigor Authors  Mandelbaum et al (2005)  Hewett et al. (1999)  Myklebust et al. (2003)  Soderman et al. (2000)  Petersen et al. (2005)  Caraffa et al. (1996)  Heidt et al. (2000)  Randomization  N  N  N  Y  N  N  Y  Inclusion/ Exclusion criteria  Y  Y  Y  Y  Y  Y  Y  Similarity of groups at baseline  Y  N  Y  Y  Y  Y  N  Replicability  Y  Y  N  Y  N  N  N  Reliability  Y  Y  Y  N  Y  Y  N  Validity  Y  Y  Y  N  Y  Y  N  Blinding  N  N  N  N  N  N  N  Dropouts  N  Y  Y  Y  Y  N  N  Long-term results  Y  Y  Y  Y  Y  Y  Y  Adherence  Y  Y  Y  Y  N  N  N  Total score /10  7  7  7  7  6  5  3  Moderate  Moderate  Moderate  Moderate  Moderate  Weak  Weak  Rigor rating  10 Criteria for Methodological Rigor 1) Randomization: • 2 of the 7 studies randomly assigned subjects to an intervention or control group 2) Subject Inclusion and Exclusion Criteria: • High school to semi-professional athletes • Exclusions: Poor compliance; previous knee injury; geography • 6 studies targeted females; 1 study targeted males  3) Similarity of Groups at Baseline: •  5 studies reported similarities (I.e. height, weight, age, muscle flexibility, balance/ postural sway of lower extremities, sport experience)  4) Replicability of the Treatment Protocols: • •  Must have been stated within the article or have had an accessible reference Mandelbaum et al., Hewett et al., and Soderman et al. provided this  5) Outcome Measure Reliability: • •  MRI or arthroscopy for diagnosis 5 studies met this criteria  6) Outcome Measure Validity: • •  Valid if used MRI or arthroscopy for diagnosis Therefore, 5 studies also met this criteria  7) Blinding Assessment: • •  Must have blinded the subjects, treatment provider AND assessor No study met this criteria  8) Reporting of Dropouts: •  Peterson et al., Hewett et al., Mykelbust et al., and Soderman et al provided sufficient detail  9) Long Term Follow-Up: •  All studies were carried out over at least one season (> 6 months)  10) Adherence to Intervention Program: •  Unreported in Caraffa et al. and Heidt et al.  THE STUDIES  Caraffa et al. (1996) Study Design  Prospective cohort  Rigor & Level of 5 (“weak”) & IIb Evidence Duration  3 seasons  Target Population  Semi professional and amateur male soccer players  Sample Size  300 Intervention; 300 Control  Caraffa et al. (1996) Intervention  Supervision?  Progressive balance board training, stepping exercises, and “neuromuscular techniques” • 20 min/day every day during preseason, 3x/week during active season Coaches  Compliance  Not reported  Incidence  •  Program Recommended?  Yes - Significant difference was found between intervention and control groups  •  10 Intervention (0.15/team/year) • 70 Control (1.15/team/year)  Heidt et al. (2000) Study Design  Randomized Cohort  Rigor & Level of 3 (“weak”) & IIb Evidence Duration  1 season  Target Population  Female high school soccer players (ages 14-18yrs)  Sample Size  42 Intervention; 258 Control  Heidt et al. (2000) Intervention  7 week preseason program including cardiovascular, plyometrics, strength, and flexibility training (20 sessions) • 2x/week speed training treadmill sessions where grade was elevated • 1x/week plyometric session that progressed throughout 7 weeks from unidirectional to multidirectional to floor obstacles  Supervision?  Not reported  Compliance  Not reported  Incidence  •  Program Recommended?  Yes - Significant decrease in lower extremity injuries found between intervention and control groups • No significant difference in incidence of ACL injuries – authors attribute this to small sample size  •  •  1 Intervention (2.4%); 8 Control (3.1%)  Hewett et al. (1999) Study Design  Prospective cohort  Rigor & Level of 7 (“moderate”) & IIb Evidence Duration  1 season  Target Population  Female high school soccer, volleyball, and basketball players  Sample Size  366 Intervention (female); 897 Control (434 males; 463 females)  Hewett et al. (1999)  Supervision?  6 week preseason jump training program; flexibility, plyometrics, and weight training • 3x/week, 60-90 min/day, total of 18 sessions Athletic trainer, coaches, physical therapist  Compliance  70% completed 6 week program  Intervention  •  2 Intervention; 6 Control (1 male, 5 female) incidence of all knee injuries • 0.43 female control, 0.12 female intervention, 0.09 male control Yes - The untrained group had a knee injury Program Recommended? rate 3.6 times higher than the female intervention group and 4.8 times higher than the male control group.  Incidence  •  Mandelbaum et al. (2003) Study Design  Prospective cohort  Rigor & Level of 7 (“moderate”) & IIb Evidence Duration  2 years  Target Population  Amateur female soccer players (ages 14-18 yrs)  Sample Size  2000: 1041 Intervention; 1905 control • 2001: 844 Intervention; 1913 Control •  Mandelbaum et al. (2003) Intervention  20 min warm up prior to practices and games: 3 warm-up techniques, 5 stretches, 3 strengthening ex’s, 5 plyometric ex’s, 3 soccer specific agility drills  Supervision? Compliance  Coaches  Incidence  •  •  2000: 96.15%; 2001: 100%  2000: 2 Intervention (0.05/athlete/1000 exposures); 32 Control (0.47/athlete/1000 exposures) • 2001: 4 Intervention (0.13/athlete/1000 exposures); 35 Control (0.51/athlete/1000 exposures)  Mandelbaum et al. (2003) Program Recommended?  Yes - Significant difference was found between intervention and control groups with 88% reduction/athlete in 2000 season and 74% reduction/athlete in 2001 season  Myklebust et al. (2003) Study Design  Prospective cohort  Rigor & Level of 7 (“moderate”) & IIb Evidence Duration  3 seasons (1 control; 2 intervention seasons)  Target Population  Female handball players  Sample Size  •  1998/99: Control Season 942 • 1999/2000: Intervention Season 855 • 2000/01: Intervention Season 850  Myklebust et al. (2003) Intervention  Supervision? Compliance  15 min circuit of floor ex’s, wobble board ex’s, balance mat ex’s • 3x/week during 5-7 week training period then 1x/week during season Coaches in first season, physiotherapists in second season • 1999/2000: 26% of teams fulfilled compliance criteria (42% elite division) • 2000/01: 29% of teams fulfilled compliance criteria (50% elite division) •  Myklebust et al. (2003) Incidence  Control season: 29 (0.14/1000 playerhours) entire cohort, 13 elite division • First Intervention season: 23 (0.13/1000 player-hours) entire cohort,6 elite division • Second intervention season: 17 (0.09/1000 player -hours) entire cohort, 5 elite division •  Yes - Although no significant difference Program Recommended? was found between intervention and  control seasons across the entire cohort, there was a significant difference between those who completed the program and those who didn’t in the elite division  Petersen et al. (2005) Study Design  Prospective cohort  Rigor & Level of Evidence  6 (“moderate”) & IIb  Duration  1 season  Target Population Semi-professional and amateur female handball players Sample Size  134 Intervention; 142 Control  Petersen et al. (2005)  Supervision?  Six phase balance board and jump exercise program • 3x/week preseason (8 weeks), 1 x week competitive season 10 min/ session Coaches  Compliance  Not reported  Incidence  1 Intervention (0.04/1000 hours exposure*); 5 Control (0.21/1000 hour exposure)  Intervention  •  Yes - Although no significant difference was Program Recommended? found between intervention and control groups  Soderman et al. (2000) Study Design  Randomized cohort  Rigor & Level of 7 (“moderate”) & IIb Evidence Duration  1 season  Target Population  Female soccer players (2nd and 3rd Swedish Divisions)  Sample Size  62 Intervention; 78 Control  Soderman et al. (2000) Intervention  Supervision?  Balance board exercises each day for 30 days, then 3x/week for remainder of season • 10-15 min/ session Self – home program  Compliance  70%  Incidence  4 Intervention; 1 Control  •  • No - Significantly higher incidence rate of Program Recommended? major injuries found in intervention group  No significant difference in minor and moderate injuries was found between intervention and control groups •  DISCUSSION & IMPLICATIONS  Methodological Rigor & Levels of Evidence z Rigor  and levels of evidence were moderate z Major contributors to low quality: – Randomization – Blinding  z Nature  of study designs makes these difficult  Intervention Characteristics z Phase of implementation: – Pre-season – Competitive season  z Type of intervention: – – – – – –  Balance/proprioception Strength Agility Flexibility Plyometrics Combination  z Other training parameters (i.e. frequency, duration, progression, etc.)  Significance z  All studies except 1 found a decrease in incidence of ACL injury – Soderman et al. showed a trend towards an increase in  ACL injury in the intervention group z z  Caraffa et al., Hewett et al., and Mandelbaum et al. found statistically significant differences Myklebust et al. found a significant difference between intervention and control groups only in the elite handball division  Implications for Clinical Practice 1)  There is moderate evidence to support the use balance/proprioceptive training in ACL injury prevention.  Implications for Clinical Practice 2)  There is moderate evidence to support the use of plyometric training in combination with other training components injury prevention of ACL injury.  Implications for Clinical Practice 3)  There is promising evidence that balance/proprioception training, strength training and plyometric training when incorporated into a comprehensive training protocol may be effective in reducing the incidence of ACL injury. - Details insufficient  Implications for Clinical Practice 4)  There is moderate evidence that training implemented in the preseason and/or competitive season is effective for ACL injury prevention.  Challenges in Drawing Conclusions z Quality  of studies z Lack of program details z Compliance z Heterogeneity: – Intervention parameters – Subjects – Duration  Implications for Future Research z Isolation  of program components z More rigorous studies z Careful documentation to allow replicability of training programs z Monitoring and reporting compliance z Intervention parameters need to be established z Effect of interventions on age and gender  Limitations of Our Review z Only  used publications in English z Lack of correspondence from experts z Only used articles accessible free of charge to UBC students  QUESTION PERIOD Thank you for your attention!  REFERENCES  Andriacchi TP, Briant PL, Bevill SL, Koo S. Rotational changes at the knee after ACL injury cause cartilage thinning. Clinical Orthopaedics & Related Research 2006;442:39-44. Arendt E, Dick R. Knee Injury Patterns among Men and Women in Collegiate Basketball and Soccer. NCAA Data and Review of Literature. Am J Sports Med 1995;23:694-701. Besier TF, Lloyd DG, Ackland TR, Cochrane JL. Anticipatory effects on knee joint loading during running and cutting maneuvers. Med Sci Sports Exerc 2001;33:1176-1181. Caraffa A, Cerulli G, Projetti M, Aisa G, Rizzo A. Prevention of anterior crucuate ligament injuries in soccer; A prospective controlled study of proprioceptive training. Knee Surg, Sports Traumatol, Arthrosc 1996;4:19-21. Fithian DC, Paxton LW, Goltz DH. Fate of the anterior cruciate ligament-injured knee. Orthopedic Clinics of North America 2002;33. Heidt RS, Sweeterman LM, Carlonas RL, Traub JA, Tekulve FX. Avoidance of Soccer Injuries with Preseason Conditioning. American Orthopaedic Society for Sports Medicine 2000;28:659-662. Hewett T, Myer G, Ford F. Anterior cruciate ligament injuries in female athletes. Part 1, Mechanisms and Risk Factors. Am J Sports Med 2006;34:299-311. Hewett TE, Lindenfeld TN, Riccobene JV, Noyes FR. The effect of neuromuscular traiing on the incidence of knee injury in female athletes. A prospective study. Am J Sports Med 1999;27:699-706. Mandelbaum BR, Silvers HJ, Watanabe DS, Knarr JF, Thomas SD, Griffin, LY, Kirkendall DT, Garrett W. Effectiveness of a neuromuscular and proprioceptive training program in preventing anterior cruciate ligament injuries in female athletes: 2-year follow-up. Am J Sports Med 2005;33:1003-1010. Medlicott MS, Harris SR. A systematic review of the effectiveness of exercise, manual therapy, electrotherapy, relaxation training, and biofeedback in the management of temporomandibular disorder. Phys Ther 2006;86:955-975.  Megens A, Harris SR. 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